Introduction to quality standards and indicators
How to cite this article: Raj R, McGuire H, Dominguez PP. Introduction to quality standards and indicators. IHOPE J Ophthalmol 2022;1:46-9.
The objective of this article is to describe NICE’s role regarding quality improvement in health and social care in England and to gain an insight into how NICE quality standards and indicators are used in the health and social care system. NICE is the national point of reference for advice on safe, effective, and cost-effective health and social care. NICE achieves this by providing advice aligned to the needs, uses, and demands of the resource constrained system. NICE’s role in quality improvement follows a stepwise progression starting with evidence-based guidance and recommendations through to quality standards and indicators. These are aimed to contribute to improved outcomes in health and social care.
Quality outcome frameworks
The objective of this article is to describe NICE’s role regarding quality improvement in health and social care in England and to gain an insight into how NICE quality standards and indicators are used in the health and social care system.
NICE is the national point of reference for advice on safe, effective, and cost-effective health and social care. NICE achieves this by providing advice aligned to the needs, uses, and demands of the resource constrained system. NICE’s role in quality improvement follows a stepwise progression starting with evidence-based guidance and recommendations through to quality standards and indicators. These are aimed to contribute to improved outcomes in health and social care.
A NICE quality standard is a web-based product consisting of a set of prioritized statements designed to drive quality improvements within a particular area of health or care. It also provides information on how to measure progress. A NICE quality standard is usually derived from a NICE guideline or a NICE accredited guideline and includes information for the different audiences that use the standard, including commissioners, service providers, health-care professionals, and people receiving care. Each statement has a time frame, specific detail of the intervention of interest, and each statement highlights areas of equality and diversity. The product includes accompanying resources such as baseline assessment tools and a list of supporting organizations.
They are developed by an independent quality standard advisory committee over 40 weeks and complement or sit alongside the source NICE guideline. Their priority domains are areas of unwarranted variations in care which requires improvement. NICE quality standards are designed to be adapted for use in local settings and as such as are not formally tested. They focus on no more than five priority action statements. Each quality statement should have a strong, specific, and measurable action. They have a structure, process, and outcome measures, but at the same time, are designed to be flexible to the needs of local providers as regards to collecting data. Quality standard measures are drafted after the quality statement has been agreed and can be based on locally sourced data. All quality measures related to processes are expressed as a numerator and a denominator that define a proportion (numerator/denominator), for example, the proportion of people with asthma who have an annual review.
The development process for NICE quality standards is described in [Figure 1].
Quality Standards Advisory Committees are independent committees including standing and topic expert members. Standing committee members represent people from various professions and sectors (NHS, public health and social care sectors, the voluntary sector, and academia) to ensure input which is provided based on wide-ranging experience and expertise. For each quality standard, specialist topic expert members are often recruited from those who worked on the source NICE guideline
Topic engagement exercise. This is online, in which NICE announces its plans to develop a quality standard. Stakeholder and topic expert committee members are asked to identify areas of interest in terms of quality improvement. They are also asked to provide supporting information for their decisions
Committee Meeting 1. The first meeting is used to get agreement on the five topic areas to focus on for the standards out of the suggestions submitted during the topic engagement exercise. The discussion covers measurability, safety, equality, resource impact, current practice, availability of validated data, and the relevant guideline recommendations. The aim of the meeting is to form a measurable, feasible, and specific quality statement
Consultation. The five draft quality standards are put out for public consultation and stakeholders are invited to comment and provide supporting information. As well as being asked to provide general comments, stakeholders are sometimes asked to provide specific information regarding feasibility, focus, or local context that can be used for refining the standards
Committee Meeting 2. The second meeting is conducted after the public consultation and is used to fine tune the statements based on stakeholder feedback. This is an opportunity to agree to changes to the standard or to consider new areas for quality improvement suggested
How quality standards are used in practice
There are several ways that standards can be used, for example, as a means of:
Identifying areas for quality improvement by influencing the design and conduct of regular audits, informing needs assessments, and identifying decommissioning opportunities
Understanding how to improve care by setting goals, supporting action plans, highlighting the level at which services should be provided, and the processes needed to achieve this improvement in care
Quality assurance by developing frameworks, identifying gaps in services, benchmarking, and monitoring/ tracking changes to care, setting key performance indicators, and monitoring performance and providing evidence of service quality for regulators
Influencing commissioning by identifying local quality improvement incentive schemes, identifying support or changes needed to improve services, as well as supporting business cases along with requests for funding and resources.
NICE quality indicators are used at the national level and reflect national priorities agreed with NHS England, Public Health England, the Department of Health and Social Care, and the devolved administrations in Northern Ireland and Wales. They measure outcomes or processes linked to outcomes that reflect the improved quality of care for patients.
NICE quality indicators were introduced in 2009 with a clear link to the evidence following a validated, rigorous transparent process. Initially, indicators covered general practice only, but recently, the scope of NICE indicators has widened into a larger program of commissioned indicators.
The development process for NICE indicators is described in [Figure 2].
The indicator program has a stream of work. Indicators may be identified for development based on the priorities used in a NICE quality standard, or a need identified in a recent review of the Quality Outcome Framework (QOF). The aim of the QOF is to improve the quality of the care patients who are given by rewarding practices for the quality of care they provide to their patients. It is based on several indicators across a range of key areas of clinical care and public health. The priority is to develop indicators for specific patient groups based on likely impact rather than on a broad range of topics. NICE indicators are also aligned to wider NHS and relevant national priorities.
The independent indicator advisory committee is formed by 20 standing committee members including primary and secondary care professionals, commissioners, public health and social care professionals, patients or service users, and their careers. If topic specific experts are required, they will be invited for part of the relevant committee meeting.
The committee meeting discussion includes topics such as:
Importance of the indicator in terms of priority for the health or social care service
Quality of the evidence base
The specification in terms of the defined components necessary to develop the indicator, including numerator, denominator, and exclusions in terms of population
Feasibility of the indicator to measure what it is designed to measure
Plans for data collection
Acceptability in terms of assessing performance that is attributable to or within the control of the end-user
Risk of unintended consequences.
Testing and piloting are the keys to identifying potential problems before the indicators are being implemented. A full cycle of testing for a single indicator takes approximately 7 months.
The level of testing is decided on a case-by-case basis and can take different forms.
How NICE indicators are used in practice
NICE indicators are used in national frameworks, especially the QOF incentives framework. The QOF led to financial incentives for the general practitioners, whose earnings increased by 25% if indicators were met. This, in turn, contributed to improvements in the quality of care. NICE indicators are also used in non-incentives based national improvement programs and local improvement packages.
While NICE guidelines are a comprehensive set of recommendations for a particular disease or condition (see paper 1 of this series) (https://ihopejournalofophthalmology.com/current-issue/ ), NICE quality standards are a concise set of prioritized statements designed to drive and measure quality improvement with a particular area of care. NICE indicators measure outcomes that reflect the quality of care, a process which is linked to improve outcomes.
Declaration of the patient consent
Patient’s consent not required as there are no patients in this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
- Available from: https://digital.nhs.uk/data-and-information/publications/statistical/quality-and-outcomes-framework-achievement-prevalence-and-exceptions-data#summary [Last accessed on 2022 Mar 30]